Socioeconomic Inequalities
in Health in Spain
Social Determinants and Inequalities in Health Working Group
Asunción Ruiz de la Sierra
Ministry of Health & Consumer Affairs. Spain
Brussels May 7th 2007
80s-90s Policies
ƒ The reform of the social security system in which the
pensions paid by Social Security System, and the
benefits for illness and unemployment are the main
lines of social protections.
ƒ An increase of public funds for social protection.
ƒ The implementation of more progressive taxation
policies.
ƒ The General Service Act (1986) established the
National Health System which lead to an almost
universal coverage of health care services, public
financing, political devolution the the autonomous
communities of health services and a new model of
primary care.
Spanish National Health
System
By 1986 the General Health Act
transformed the social security system
into a National Health System.
The main principles regulated by the
General Health Act 14/1986
ƒ Public funding, with universal, free health services at the time of use
ƒ Specific rights and duties for citizens and for public authorities
ƒ Devolution of health affairs to the Autonomous Communities
ƒ Provision of holistic health care, aiming to achieve high quality, with
proper evaluation and control
ƒ Inclusion of the different public health structures and services in the
National Health System
Equity on Health Policies
ƒ Cohesion & Quality Act (2003).
ƒ Social Inclusion Strategy (2006).
ƒ Health Quality Plan (2006).
Act 16/2003 of 28 May on Cohesion and
Quality in the National Health System
ƒ The Inter-Territorial Board as the coordinating body of the National
Health System.
ƒ The devolution of powers to the Autonomous Communities is a
means of bringing the management of health care closer to citizens
and thus guaranteeing equity, quality and participation.
ƒ Practical experience of relations between the State and the
Autonomous Communities in the area of health protection provides
important references for the development of cohesion in the State of
Autonomous Communities.
ƒ A common identity for the National Health System, based on the
constitutional principles of unity, autonomy and solidarity.
Citizens’ opinion about equity in the Access to
the NHS
ƒ The majority of the citizens think that the access to the
Spanish Health Care System is equitable besides of age,
income and nationality.
ƒ The 87,8% of the population believes that there is not
gender discrimination in the access to the National Health
Care System.
ƒ However, the 46,1% of the population think that the
place of residence (rural or urban ) has influence in the
access to the HCS.
Barómetro Sanitario 2006
Social Inclusion Strategy (2006)
Challenges ahead
ƒ BBreak the intergenerational transmission of poverty, in particular by
reducing the high rate of early school leavers. The new Education Law set
out to address this issue, but reaching the 2010 target will require sustained
and comprehensive efforts.
ƒ TContinue efforts to promote the active inclusion of vulnerable groups, such
as the immigrant population and youth, and of women by reducing persistent
inequalities in income, access to education and labour integration and to
promote affordable housing through an adequate and long-term public and
rental housing policy.
ƒ TEnable a greater participation, notably of women and older workers, in the
labour market; which would help secure the sustainability and adequacy of
the pension system
National Health System Quality Plan
ƒTo improve quality and increase cohesion in the health
system by guaranteeing equity in health care for the nation
regardless of place of residence and by ensuring that care is
of the highest quality.
ƒThe plan establishes 6 major action areas (protection,
promoting health and prevention; fostering equity; human
resources; clinical excellence; use of new technologies and
increasing system transparency).
ƒIt involves 12 strategies, 41 objectives and 189
measures, which have to be implemented in conjunction
with the Autonomous Regions, professionals, patients
and social stakeholders.
Introduction
Reports of inequalities in health
In 1993 the Ministry of Health of the Spanish Socialist
Government appointed a Scientific Commission to study
socioeconomic inequalities in health. A report was
published in 1996.
A New Report (2005) is shown in this presentation.
Objectives
ƒ To describe inequalities in overall mortality and in avoidable
mortality in the Autonomous Communities of Spain in men
and women between 2000 and 2002, as well as trends
between 1981-2002.
ƒ To describe inequalities in self-perceived health in the
Autonomous Communities of Spain in men and women in
2003, as well as trends between 1993-2003.
ƒ To describe general macro policies and some examples of
interventions to reduce socioeconomic inequalities in health.
Mortality in the Autonomous
Communities
1981-2002
Distribution of overall mortality in the Autonomous
Communities of Spain,men and women for 2000-2002
Age-SMR per 100.000 habitants
C-Le
Rio
C-Man
Nav
Ara
Mad
Cat
PV
Gal
Ctb
Ext
Mur
C.Val
Bal
Ast
And
Can
Ce-Me
HMales
M
Females
0
300
600
900
1200
1500
Distribution in quintiles of overall mortality in the
Autonomous Communities of Spain, men and women for
2000-2002
Age-SMR per 100.000 habitants
Men
All causes of
death
in males
Women
All causes of
death
in females
Distribution of avoidable mortality in the Autonomous
Communities of Spain,men and women for 2000-2002
Age-SMR per 100.000 habitants
Mad
C-Ma
Ctb
C-Le
PV
Cat
Ara
Nav
Rio
Bal
Ext
Mur
C.Val
Gal
And
Ast
Can
Ce-
HMales
MFemales
0
50
100
150
200
Distribution in quintiles of avoidable mortality in the
Autonomous Communities of Spain, men and women for
2000-2002
Age-SMR per 100.000 habitants
Men
All causes of
avoidable death in
males
Women
All causes of
avoidable death in
females
Self-perceived health inequalities
1993-2003
Trends in poor self-perceived health by gender,
1993-2003
Age-standardized %
50%
40%
30%
Men
Women
20%
10%
0%
1993
1995
1997
2001
2003
Geographic distribution of poor self-perceived health,
in Autonomous Communities of Spain 2003
Men
Men
Poor self-perceived health
Women
Women
Poor self-perceived health
Poor self-perceived health by social class, 2003
Men
CS I
CS II
CS III
CS IV
CS V
Women
CS I
CS II
CS III
CS IV
CS V
0%
20%
Very good
40%
Good
60%
Regular
Poor
80%
Very poor
100%
Trends in poor self-perceived health by social class,
1993-2003
Age-standardized %
50%
40%
30%
Non manual
Manual
20%
10%
0%
1993
1995
Men
1997
2001
2003
1993
1995
1997
Women
2001
2003
Conclusions
ƒ Overall mortality shows a north south territorial pattern with
a higher mortality found in the south regions of Spain:
Canary Islands, the cities of Ceuta and Melilla and
Andalucia in men and women.
ƒ Avoidable mortality in men and women shows a higher
mortality in Canary Islands, the cities of Ceuta and Melilla
but without a clear territorial pattern.
ƒ Overall mortality and avoidable mortality in men and women
shows a decreasing trend in all Autonomous Communities
in recent years.
ƒ 28% of men and 35% of women declared poor perceived
health, percentages that were stable through the years.
ƒ People of the South and West of Spain had higher
percentages of poor perceived health, as well as people of
disadvantaged social classes.
This paper was produced for a meeting organized by Health & Consumer Protection DG and represents the views of its author on the
subject. These views have not been adopted or in any way approved by the Commission and should not be relied upon as a statement of
the Commission's or Health & Consumer Protection DG's views. The European Commission does not guarantee the accuracy of the data
included in this paper, nor does it accept responsibility for any use made thereof.